A nurse delegates the task of neonatal vital sign assessment to a ...

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A nurse delegates the task of neonatal vital sign assessment to a nurse technician. The nurse should instruct the technician to:
 
  1. Report any neonate using abdominal muscles to breathe.
   2. Report any neonate with apnea for 10 seconds.
   3. Count respirations for 15 seconds and multiply by 4 to get the rate for 1 minute.
   4. Report any neonate with a breathing pause that lasts 20 seconds or longer.

Question 2

The nurse is taking care of a child who is showing signs of imminent death. What changes should the nurse expect to see related to the cardiovascular system?
 
  1. An increase in the volume of Korotkoff's sounds
  2. Mottling, cool and clammy skin
  3. Peripheral pulses will remain when the heart beat is not heard on auscultation.
  4. Increase in cardiac output

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Answer to Question 1

4
Rationale:
1. It's normal for neonates to use abdominal muscles for breathing.
2. A breathing pause of 10 seconds or less is called periodic breathing, and is a normal pattern for a neonate.
3. Respirations should be counted for 1 minute, not 15 seconds.
4. The abnormal assessment finding for vital signs that the nurse should instruct a nurse technician to report is any breathing pause by a neonate lasting longer than 20 seconds. This can indicate apnea, and could lead to an apparent life-threatening event (ALTE).
Assessment
Safe, Effective Care Environment
Analysis
Learning Outcome 25.3 Assess the child's respiratory signs and symptoms to distinguish between mild, moderate, and severe respiratory distress, and identify the appropriate nursing actions for each level of severity.

Answer to Question 2

2
Rationale 1: A change in pulse pressure and a decrease in the volume of Korotkoff's sounds indicate imminent death.
Rationale 2: Peripheral circulation decreases, leading to diaphoresis, clammy and cool skin, and changes in skin coloring such as mottling or cyanosis.
Rationale 3: The heart rate might initially increase as hypoxia develops, then the heart rate and blood pressure decrease, resulting in decreased cardiac output.
Rationale 4: The heart rate and blood pressure decrease, resulting in decreased cardiac output, which is a sign of imminent death.
Global Rationale: